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OIG questions Texas Medicaid oversight

August 18, 2014 Washington — A report from the U.S. Department of Health and Human Services Office of Inspector General cited the Texas Medicaid and Healthcare Partnership for failing to determine medical necessity in the pre-authorization process for orthodontic services and said the state agency is ultimately responsible for ensuring proper review of pre-authorization requests.

The report is unclear about what this will mean to providers and whether good faith reliance on the pre-authorization process will preclude requests for refunds.

The Texas Health and Human Services Commission response appended to the report said in part, "HHSC relied to its detriment on its third-party administrator, Xerox doing business as Texas Medicaid and Healthcare Partnership, to manage the Medicaid orthodontia prior authorization program effectively and in compliance with HHSC's policy for orthodontia services." The TMHP "management response" included detailed comments on the OIG findings and recommendations.